James, Patricia dob 02/01/1926 77 & 1/12 y/o 3-2-03
941-0000 000-0000 Hospital MR #00000
Mercy Folsom Hospital, Med Surg Ward
983-7460,
Fax 983-7548, ooo@hospital1.com
Admission H&P
CC: 10 d cough and fever
HPI: 77 y/o admitted from the clinic with the above. There was moderate shortness of breath and some L lateral pleuritic chest pain. Other than as above, ROS neg: [HEENT: no vision changes nor eye problems; no nasal nor sinus sx; ears ok w/o hearing loss, changes or pain; mouth and teeth w/o sx; neck w/o sx. GI: BM’s 5-8/week w/o blood or pain. No nausea, vomiting, diarrhea nor constipation.. GU: no dysuria nor nocturia nor urine complaints. Skin: no rashes nor other complaints. Endo: no complaints. Psych: no complaints.]
Exam: crackles & some dullness L lung base; HR 110/min, oximetry O2 sat 90%, 130/85; moderately toxic appearing; no murmurs, legs dry, no NVD. [otherwise general female exam w/ only normal findings Except as above, there were only normal findings, including: NAD nontoxic, & normal physical: [heent: perrla fundii wnl; nasal mbs wnl; Tm's wnl; OP wnl; neck wnl; gi: nontender w/o HSKM; CVA nontender; neuromuscular exam grossly wnl w/o deficit; psych wnl; endo wnl; skin wnl]
A: pneumonia, COPD
P: wbc 17.8 w/ left shift; CMP wnl othewise; CXR LLL infiltrate; EKG wnl
see admission orders
Note:
this table usually adds some information at each visit http: //coremedicalconcepts.com PMH: gyn hx infra, appy ~ 15
y/o; Crohn's; urinary incontinence
but no fistula, just loss of angle per urology; seizure disorder, DJD neck,
HH, COPD, recurrent UTI, monilial angular stomatitis, partial small bowel obstruction resection 1970, 1988; B12
injection need; no tobacco x ‘85; TIA ~’75, stroke? per Dr Goldstein hx |
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FH: no breast ca |
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Problem Progress List |
03/14/01 |
3/00 |
4/1997 |
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Cholesterol -
HDL |
195-106 |
195-106 |
226-118 |
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LDL -- trigly |
69-100 |
69-100 |
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‘ “ weight ® |
106 |
90# |
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Ongoing Meds |
Past meds used & notes
about them below: |
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Dilantin
100 mg tid |
x
‘85 for seizure |
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Estropipate
0.625 qd |
(=ogen=orthoest);
previously on premarin 2/98; TAH BSO
‘70, bladder suspension, wnl mammogram 9’98 |
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Hcthz
25 mg q AM |
x
02/00; previously, hcthz 25 mg q AM or dyazide x ‘95 |
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K+
8 meq qd |
X
8/4/00 |
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Stopped |
x
02/00; previously, lorazepam 0.5 mg 1-2 tid prn x ‘96; # 60 mr2 03/08/99 |
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Prednisone
5 mg qd |
x
1970 |
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Pentasa
250 mg 4 qid |
x
1/00; previously, azulfidine 500 mg 1-2 qid x 2/98; stopped 2/98; hx asacol
400 mg 2 tid ‘96; occl prednisone x 10 yrs; vit B12 injections 09/08/99 |
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Quinine
SO4 325 mg hs prn |
x
before ‘94; B12 q several months |
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Monthly
B12 injection |
stopped
lomotil 1-2 qid if needed x years; #240 mr6
03/29/99 |
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Darvocet
N 100 1 q 4-6 hr prn pain max #30/mo |
zantac
150 mg hs x ‘93; bentyl prn; occl lomotil; B12 1000 mg IM 06/18/99 |
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vicodin
5 mg q 4-6 hr prn pain max #30/mo |
for
neck pain, see MFH ER visit 05'01 |
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Selected test results: cardiac w/u ETT + 8’95,
echo heart Normal 7’95; gi Dr. Schneiderman 4/1/98; colon wnl except
diverticulosis 5/12/98; wnl EKG and CXR ‘97; CBC sgot alk phos lipase wnl but
UA and C&S + 03/99; urine C&S neg 03/29/99; CXR probable old
histoplasmosis 06/99; R hip post-op pelvic changes noted, w/ diffuse osteopenia w/o advanced arthropathy
12/99; CBC ESR K+ giardia Ag stool O&P
C- difficile wnl 2'00; neck XR trace anterolisthesis C4 on 5, minimal
DDD neck 8/00; CBC CMP UA lipids ESR
SPE & TSH wnl except ¯ K+ 3.3, FBS 159 [Hgb A1C 5.6], & UTI sensitive to sulfa 8/00; wnl CXR neck
XR & EKG MFH ER 05'01; XR L5-S1 DDD 10'01 |
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ADR: penicillin rash, macrobid & motrin
gastritis Immunizations: pneumovax & Td 5’95; flu 11/6/99 &
10/29/01 |
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Office visit record: ... ct’d 10/1/01
chronic LBP x '97 fall, psoas myalgia?, seborrheic keratosis L preauricular
region, pointed L malar red papule 10/29/01
seborrheic keratosis, facial papule, flu & B12 shot |
12/10/01
labyrinthitis, neck myalgia 1/2/02 Crohn’s |
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John Smith, MD